MEMORANDUM OF AGREEMENT

This Memorandum of Agreement executed on this _____Date -

________ at Silang Cavite, Philippines by and between.
JULLIENNE LYING-IN AND MATERNITY CLINIC, a business entity
duly registered with the Department of Trade and Industry with business
address at Block 36 Lot 9 Xone 11 AFP Housing, Bulihan, Silang, Cavite
and represented by the ownier / sole proprietor RODELIZA FRENANDEZ
EMPIALES, hereinafter referred to as the “SERVICE PROVIDER”
and
NAME OF HOSPITAL, a medical and a corporate entity duly registered
in accordance with the laws of the Republic of the Philippines with
business at KM 43 By Pass, Silang, Cavite represented by its MEDICAL
DIRECTOR, NAME OF DOCTOR/OWNER, hereinafter referred to as the
REFERRAL HOSPITAL;
and
NAME OF OB-GYNE, a medical practitioner (OBSTETRICIAN-
GYNECOLOGIST) with licensed number_______, and NAME OF
PEDIATRICIAN, a medical practitioner (PEDIATRICIAN) with License No.
________, both are presently affiliated at name of hospital, hereinafter
referred to as the “PARTNER PHYSICIANS”.
Witnesseth
WHEREAS, Jullienne Lying-In and Maternity Clinic (SERVICE
PROVIDER) is engaged in the service of providing maternity care to
pregnant women offering prenatal, midwife-assisted delivery and post
natal care to mothers and newborns;
WHEREAS, there are onset risk cases which the SERVICE PROVIDER
can handle better with the help of professional medical practitioners after
examination of patients and determination that they will require further
adept medical supervision for both mothers and newborns;
WHEREAS, the parties herto – the SERVICE PROVIDER and PARTNER
PHYSICIANS forge a partnership concerning onset risk cases to facilitate
patients admission to the REFERRAL HOSPITAL bearing in mind the best
interest of the mother and the unborn or newborn, as the case may be;
WHEREAS, all onset risk cases handled by herein SERVICE
PROVIDER and PARTNER PHYSICIANS shall be exclusively referred to the
REFERRAL HOSPITAL subject to Philhealth membership of patients or
beneficiaries;
WHEREAS, the trilateral relationship is meant to maximize the
Maternity Care Package available to Philhealth members and their
beneficiaries and make available its availment to a wider patient base;
WHEREAS, essentially, the purpose of this Memorandum of
Agreement is to extend the REFERRAL HOSPITAL’S accreditation use to
the SERVICE PROVIDER in relation to onset risk cases.
 NOW THEREFORE, for and in consideration of the foregoing
premises, the hereinafter parties have agreed to the following terms and
conditions.

TERMS AND CONDITIONS

Article I
DEFINITIONS OF TERMS
1. The Maternity Care Package is a PhilHealth Outpatient Benefit
Package that covers payment for the following services for the first
and second low-risk pregnancies, prenatal care, normal birth,
routine newborn care, postpartum care, and family planning,
rendered by the PhilHealth-Accredited Outpatient Clinic.

2. Low-risk pregnancy with no identified risk factors. Normal birth is

defined as spontaneous is onset, low-risk at the start of the labor,
and remaining so throughout labor and delivery. The infant is born
spontaneously in the vertex position between 37 and 40 completed
weeks pregnancy. After birth, mother and infant are in good
condition.

3. The REFERRAL HOSPITAL is a PhilHealth-Accredited secondary or

tertiary hospital equipped with state-of-the-art medical instruments
and equipments needed for the management of obstetric or
newborn complications.

4. The SERVICE PROVIDER is an outpatient and a business entity

known as JULLIENNE LYIN-IN AND MATERNITY CLINIC duly accredited
by PhilHealth for the Maternity Care Package. It is non-hospital
outpatient facility with adequate facilities and competently trained
staff capable of providing all the maternal and neonatal services.

5. REFERRAL is the process by which the SERVICE PROVIDER directs

the patient to the REFERRAL HOSPITAL due to onset risk, for further
management of patient’s care.

6. PARTNER PHYSICISIANs are highly qualified medical practitioners in

their own field of profession (OBSTETRICIAN-GYNECOLOGY and
PEDIATRICIANS) who will provide further management of the mother
and the new-born baby.

Article II
OBLIGATION OF THE SERVICE PROVIDER
1. The SERVICE PROVIDER shall render prenatal, birth delivery,
routine newborn care, and postpartum services to female
beneficiaries during their first and second low-risk pregnancies and
normal deliveries.

2. The SERVICE PROVIDER shall be available to attend to all patients at

all times, especially during intra-partum.

3. The SERVICE PROVIDER shall be abide by/comply with the

prescribed clinical pathways and practices guidelines for the
Maternity Care Package.

4. The SERVICE PROVIDERshall do a pregnancy risk during the first

prenatal visit of the patient.

5. The SERVICE PROVIDER shall provide ambulance/vehicle to

transport patients to the referral hospital should an emergency
arise related to complaints on obstetric/gynecological/neonatal
cases.

Article III
OBLIGATION OF PARTNER PHYSICIAN
1. The PARTNER PHYSICIANS in their own judgment and direction
coordinate with the SERVICE PROVIDER of any patients who
presents with any of the EXCLUSIO CRITERIA and if necessary shall
refer the patients to the REFERRAL HOSPITAL for Obstetric
complication and at the soonest possible time.
1.1 History of previous major obstetric/gynecologic operative
interventions (e.g. caesarian Section, Salpingectomy for ectopic
pregnancy, Oephorectomy).
1.2 History of three (3) or more miscarriages, or one (1) stillbirth.
1.3 Maternal age under 19 years old.
1.4 Elderly primis with maternal age of 35 years old.
1.5 Multiple pregnancy (e.g. twins, triplets, etc.,)
1.6 Abnormal fetal presentation (e.g. breech)
1.7 Placenta abnormalities (e.g. low-lying placenta, placenta previa)
1.8 Uterine abnormalities (e.g. myoma uteri)
1.9 Ovarian abnormalities (e.g. ovarian cyst)
1.10 History of medical conditions (e.g. hypertension, heart
disease, diabetes, thyroid disorders, obesity, moderate-serve
asthma, pre-eclampsia, epilepsy, bleeding disorders)
1.11 Other risk factors that may arise during present pregnancy
(e.g. premature contractions, vaginal bleeding), that the midwife
perceives to warrant a referral to an obstetrician / physician for
further management.
 2. The PARTNER PHYSICIAN and with the conformity of the REFERRAL
HOSPITAL is authorized to endorsed the patient of the SERVICE
PROVIDER.

Article IV
OBLIGATIONS OF THE REFERRAL HOSPITAL
1. The REFERRAL HOSPITAL shall accept ALL patients properly referred
by the SERVICE PROVIDER.

2. The REFERRAL HOSPITAL shall accept referrals on a 24-hour basis

for obstetric / gynecologic/ neonatal emergency cases.

3. The REFERRAL HOSPITAL shall be entitled to reimbursement of

claims in accordance with existing NHIP in-patient benefits.

Article V
COMMON PROVISIONS
The herein PARTIES agree that their attendance to the patients shall
be independent of each other, hence, each PARTY shall be individually
responsible for any incident that may occur during the time the patient is
under his/her care. The determination of the liabilities of PARTIES in the
care of the patients shall depend upon the specific factual circumstance
all around the patients.

IN WITNESS WHEREOF, the parties have hereunto signed this

MEMORANDUM OF AGREEMENT this _______Date_______ in Silang, Cavite.

Signed in behalf of the Service Provider RODELIZA F. EMPIALES

Jullienne Lying-in and Maternity
Clinic

Signed in behalf of Referral Hospital NAME OF

DIRECTOR/OWNER
Referral Hospital’s Name

Signed in behalf of the Partner Physician NAME OF THE DOCTOR

Obstetrician –
Gynecologist

NAME OF THE DOCTOR

Pediatrician
 WITNESS:
______________________________
_______________________________

ACKNOWLEDGEMENT
REPUBLIC OF THE PHILIPPINES
SILANG, CAVITE
BEFORE ME, this ____Date_ in the Municipality of Silang, Cavite,
personally appeared the following persons:
NAME PRC License No.
RODELIZA F. EMPIALES _____________
NAME OF DIRECTOR _____________
NAME OF OB-GYNE _____________
NAME OF PEDIATRICIAN _____________
known to me and to be the same persons who executed the foregoing
instruments, and acknowledged to me that the same is their voluntary act
and deed.
These instruments consisting of four (4) pages, has been signed on
the left margin of each and every page thereof by the parties and their
witness, and sealed with my notarial seal.
WITNESS MY HAND AND SEAL in the place and on the date first
above written.

Doc No. ____________

Page No. ____________
Book No. ____________
Series of 2010